Merrick I. Ross

Classifying local disease recurrences after breast conservation therapy based on location and histology: New primary tumors have more favorable outcomes than true local disease recurrences

To distinguish true local recurrences (TR) from new primary tumors (NP) and to assess whether this distinction has prognostic value in patients who develop ipsilateral breast tumor recurrences (IBTR) after breast‐conserving surgery and radiotherapy.

Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy

Meric et al. recently concluded that currently available data are not sufficient to determine conclusively whether distant metastases are caused by the development of ipsilateral breast tumor recurrence (IBTR). The authors of at least four randomized, prospective trials do not agree. For example, the National Surgical Adjuvant Breast and Bowel Project (NSABP) concluded that local recurrence is a marker for risk (and not a cause) of distant metastases. Meric et al. also concluded that it would be difficult to argue biologically that malignant cells in the primary tumor could metastasize and affect survival while arguing that malignant cells in the recurrent tumor could not. I have offered this explanation. It is likely that cancer cells begin to circulate when a tumor is very small. Cells shed from a small tumor may succumb to a variety of host defense factors—mechanical, biochemical, immunologic, etc. After breast-conserving surgery, cancer may recur locally. (Here, I prefer the term local persistence.) Patients who survive their first cancer without developing distant metastases may be expected to survive the recurrence of a similar volume of tumor, because the host defense factors that killed tumor cells from the primary tumor can be expected to kill tumor cells shed from the recurrence (persistence). Local recurrence after radical surgery has always been an ominous event. It may represent the return of malignant cells from a distant organ to the site of surgery. Local recurrence also may occur after breast-conserving surgery. This is one reason why patients who develop IBTR have a poorer prognosis compared with patients who do not. In NSABP trial B-06, patients who developed local recurrence were 3.41 times as likely to also develop distant metastases. This is not evidence that IBTR is the cause of tumor spread. Investigators from the NSABP trial B-06 recently reported a marginally significant decrease in breast cancer deaths among women who received postoperative radiotherapy. This finding is fully compatible with the above hypothesis. The excess deaths in the unirradiated group may have occurred in women whose recurrences exceeded their primary tumors in terms of volume. I asked the NSABP for data on the size of tumor recurrences and was told that such data are not available. Meric et al. discussed the possible survival advantage associated with local control. They cited important studies that will help us fine-tune our understanding of this dilemma. However, the past 15 years have witnessed a dramatic change in our understanding of local recurrence. Local persistence seldom metastasizes in patients with the soft tissue sarcomas, rectal carcinoma, melanoma, and other solid tumors. Investigators at The University of Texas M. D. Anderson 2522

Breast conservation after neoadjuvant chemotherapy: A prognostic index for clinical decision-making

The appropriate selection criteria for breast‐conserving therapy (BCT) after neoadjuvant chemotherapy are poorly defined. The purpose of the current report was to develop a prognostic index to help refine selection criteria and to serve as a general framework for clinical decision‐making for patients treated by this multimodality approach.

Contralateral prophylactic mastectomy: Predictors of significant histologic findings

Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high‐risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM.

Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry

The ideal pathologic assessment of sentinel lymph nodes (SLNs) in patients with breast carcinoma remains controversial. The authors evaluated how detailed assessment of SLNs using immunohistochemistry (IHC) and serial sectioning would affect treatment decisions and outcomes in patients with breast carcinoma who had negative SLNs on standard hematoxylin and eosin staining.

Adjuvant irradiation for cervical lymph node metastases from melanoma

The risk of regional disease recurrence after surgery alone for lymph node metastases from melanoma is well documented. The role of adjuvant irradiation remains controversial.

Assessment of the role of sentinel lymph node biopsy for primary cutaneous desmoplastic melanoma

The role of sentinel lymph node biopsy (SLNB) in the treatment of desmoplastic melanoma (DM) remains undefined. The purpose of this study was to evaluate the use of SLNB for DM.

Implications of lymphatic drainage to unusual sentinel lymph node sites in patients with primary cutaneous melanoma

Sentinel lymphadenectomy reliably identifies the first site(s) of regional lymphatic drainage and, therefore, the most likely lymph nodes to contain occult metastasis in patients with primary cutaneous melanoma. Although in most patients lymphatic drainage from the primary melanoma first reaches a standard lymph node basin, a sentinel lymph node (SLN) may be identified in an unusual location. The objective of this study was to determine the frequency and significance of unusual sentinel lymph node drainage patterns in a large cohort of patients with primary melanoma.

Elective radiotherapy provides regional control for patients with cutaneous melanoma of the head and neck.

In the current study, the authors assessed the efficacy of elective radiotherapy in providing regional (lymph node) control in patients with cutaneous melanoma of the head and neck who were at high risk for lymph node involvement. Toxicity was also assessed.

Intramammary lymph node metastases are an independent predictor of poor outcome in patients with breast carcinoma

Breast carcinoma with intramammary lymph node (intraMLN) metastases is considered to be Stage II disease, even in the absence of axillary lymph node involvement. Nonetheless, little is known regarding the clinical significance of intraMLN metastases. The goals of the current retrospective analysis were to elucidate the clinical relevance of intraMLN metastases and to assess the relation between such metastases and outcome in patients with breast carcinoma.